• build a culture and behaviours that is responsive to feedback from workers
• ensure that the organisation focuses on learning, to continuously improve quality of care and the experience of staff, patients and service users alike
• improve staff survey scores and other worker experience metrics
• demonstrate to regulators or inspectors the work that the organisation is doing to develop their speaking-up arrangements.

• The proportion of Freedom to Speak Up Guardians who reported a positive culture of speaking up in their organisation has dropped by five percentage points on last year, to 62.8%.
• There has been a drop in the proportion of guardians who responded to the survey saying that their senior leaders support workers to speak up. This has fallen by nine percentage points on last year, to 71%.
• 10% of respondents said that their senior leaders do not understand the role of Freedom to Speak Up Guardian.

The review also found that some workers who had spoken up to national bodies had variable experiences.

The report makes recommendations for actions which national bodies and the healthcare system as whole can take to support organisations, including bringing national guidance into line with good practice and make that guidance universally applicable.

• 20,388 cases were raised with Freedom to Speak Up Guardians in 2020/21 (a 26% increase from 2019/20).
• Cases raised in NHS trusts (19,560) accounted for the vast majority of these, with a further 828 cases raised in other organisation types.
• Nurses and midwives accounted for the biggest proportion (29%) of cases raised.
• Workers spoke up about issues to do with the pandemic, including social distancing, personal protective equipment, support for workers isolating and shielding, and increased stress and exhaustion.
• Communication issues were a key learning point, including workers being informed about changes, style of communication and differing local interpretations of guidance.
• 18% of cases involve an element of patient safety/quality (down 5% form 2019/20).
• Almost 12% of cases continued to be reported as being raised anonymously.

The report identifies two models to support primary care organisations in developing their speaking up arrangements, bridging across the silos of GP, dental, optometry and pharmacy:

1. Freedom to Speak Up within an organisation – an individual organisation model – such as a GP practice or Dental surgery; or a Clinical Commissioning Group
2. Freedom to Speak Up within a network or defined structure – a partnership model – for example Primary Care Network or alliance between opticians; a local support model – eg practices supported by their local committee, CCG or NHS Trust; or an Integrated Care System Model.

Whilst organisations may vary in size, structure and business model, the promoters and barriers to speaking up are common to all settings and organisations. The report shows that the universal nature of the promoters and barriers to speaking up requires, in response, universal principles for embedding effective speaking up arrangements and implementing the Freedom to Speak Up Guardian role.

Further reading

• 2020 Freedom to Speak Up Guardian Survey Report (National Guardian's Office)
• About the Freedom to Speak Up in Healthcare programme in England (National Guardian's Office and Health Education England)
• The right - and duty - of staff to speak up (A blog by Hugh Wilkins)
• Tackling the blame culture? NHS Staff Survey Results 2020 (Patient Safety Learning)

Between 1 April 2019 to 31 March 2020, 16,199 speaking up cases were raised with  Freedom to Speak Up Guardians. This was a 32% increase compared with the  previous year in which 12,244 speaking up cases were raised with Freedom to Speak  Up Guardians. 

• Freedom to Speak Up Guardians supported speaking up in a range of  organisations, including NHS trusts, primary care organisations, independent  healthcare providers, clinical commissioning groups and non-departmental public  bodies. 
• Among NHS trusts, Freedom to Speak Up Guardians in mental health, learning  disability and community trusts and ambulance trusts, on average, dealt with more  speaking up cases.  
• Freedom to Speak Up Guardians continued to support workers from all professional  groups to speak up. Nurses continued to account for the biggest portion (28%) of cases raised with Freedom to Speak Up Guardians. 
• Administrative and clerical workers accounted for the next biggest portion of  cases raised with Freedom to Speak Up Guardians (19%), up three  percentage points on the previous year. 
• 23% of cases raised with Freedom to Speak Up Guardians  included an element of patient safety/quality. 36% included an  element of bullying and harassment.  
• 13% of cases raised with Freedom to Speak Up Guardians were  raised anonymously. 
• Detriment for speaking up was indicated in 3% of cases raised with  Freedom to Speak Up Guardians. This is lower compared to the previous year where  detriment was indicated in five per cent of cases. 
• 85% of workers who gave feedback said they would speak up  again. Workers said they would not speak up again in 3% of cases where  feedback was received.

Freedom to Speak Up Guardians are required to record all cases of speaking up that are raised to them. Your records:

• help you keep track of individual cases
• promote consistency in the handling of cases
• provide a measure of the speaking up culture in your organisation and the use of the Freedom to Speak Up Guardian route
• act as a source of intelligence enabling trends in, and barriers to, speaking up to be identified.

Cases should be recorded:

• in a consistent and systematic way
• with due regard for confidentiality
• in compliance with local data and information management, and security policies.

Confidentiality should always be respected and details of individual cases should not be shared outside the bounds of your agreement with the individual you are supporting. As a general rule, without express consent, this includes not sharing details of individual cases amongst local networks of champions/ambassadors etc. nor with other parts of your organisation, or with outside organisations.

In some circumstances confidentiality may need to be broken (for instance if there is an immediate risk of harm to an individual) – decisions on the extent of information that needs to be disclosed to enable appropriate action will need to be taken on a case-by-case basis.

The Data Protection Act 2018 and the General Data Protection Regulation (GDPR) form part of the data protection regime in the UK. You should seek advice from the experts in your organisation regarding the data you are collecting, how it is processed, stored and retained/destroyed. Be aware that your records may be requested weeks, months or even years after their creation and this should be taken into account when setting up your systems.

• Improve the office’s offer of support and guidance.
•  Further enable existing guardians to support each other.
• Take positive action to support guardians in trusts with less positive speaking up cultures.
•  Improve understanding of the impact of the guardian role, and Freedom to Speak Up culture in the NHS .
•  Develop governance arrangements and explore further the office’s standing and role in the wider system.
•  Increase reach into the primary care landscape.
•  Join-up cross system drivers for improving freedom to speak up culture.

• Between 1 April 2017 and 31 March 2019, 19,331 cases were raised to FTSU Guardians in trusts and foundation trusts.
• 12,244 cases were raised to FTSU Guardians in trusts and foundation trusts between 1 April 2018 and 31 March 2019.
• The total number of cases raised in 2018/19 was 73% higher than that raised in the 2017/18 reporting period.
• The number of cases raised in Q4 of 2018/19 was 38% higher than that raised in Q1 of the same year.

In 2018/19:

• The average number of cases per trust was largest among combined acute and community trusts (an average of 75 cases per trust reported over the year). This is the same trend as was observed in 2017/18.
• More cases (3,728, 30% of the total) were raised by nurses than other professional groups.
• 1,491 cases (12%) were raised anonymously, compared to 18% of cases the previous year.
• 3,523 cases (29%) included an element of patient safety / quality.
• 4,969 cases (41%) included an element of bullying / harassment.
• 564 cases (5%) indicated that detriment as a result of speaking up may have been experienced
• The highest number of cases in a single trust reported over the year was 270. The lowest number of cases reported was 1.

• Organisations who can support you.
• Practical tools and advice.
• Raising concern externally.
• Advice and reflections from the front line.